Multidimensional Poverty by HIV Status in Eastern and Southern Africa: A Cross-Sectional Analysis of Population-Based HIV Impact Assessment Surveys

Abstract Introduction Multidimensional poverty (deprivations in education, health, and living standards) affects people with and without HIV. We compared poverty levels by HIV status in Eastern and Southern Africa and identified indicators driving deprivations. Method We analysed the 2020–22 Population HIV Impact Assessment data from Eswatini, Lesotho, Malawi, Mozambique, Tanzania, Uganda, and Zimbabwe using the Alkire-Foster method, calculating the multidimensional poverty index (MPI), headcount ratio, and poverty intensity, using the Stata 14.2 mpi command. We classified individuals deprived in 20·0%–33·3% of indicators as vulnerable to poverty, ≥33·3% as poor, and ≥50·0% as severely poor. We estimated the number of people in each poverty category, and decomposed poverty by indicators. Analyses were survey-weighted, disaggregated by sex, residence, and age (15–24 years), and differences by HIV status tested using the Rao–Scott chi-square test (p <0·05). Results People living with HIV (PLHIV) comprised 7·1% (11·8 million) of the study population (164·9 million). PLHIV were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. In Eswatini, with the lowest poverty level, PLHIV had higher MPIs (0·248 95% CI [0·239–0·257]) than people without HIV (0·220 [0·215–0·226]). 53·7% [51·8%–55·5%], 99,000, PLHIV were poor compared to 47·5% [46·4%– 48·6%], 266,000, of people without HIV. In Mozambique, with the highest poverty level, the MPIs were similar for people living with and without HIV, but poverty remained higher among PLHIV (70·2% [67·8%– 72·5%], 1·5 million, versus 69·6% [68·6%–70·5%], 10·5 million). The intensity of poverty did not differ across the countries. Education/employment and living standards accounted most for deprivations. Interpretation Nearly three-quarters of PLHIV in Eastern and Southern Africa experienced multidimensional poverty. Integrating HIV and poverty-reduction efforts, prioritising education, employment, clean energy, water, sanitation, housing, and assets is required. Including HIV indicators in poverty surveys, and research to accelerate joint progress are required. Funding This study received no external funding Research in context Evidence before this study We searched PubMed, Google Scholar, reports by UNAIDS, UNDP, World Bank, and other grey literature, using subject headings and keyword terms ("HIV and poverty", "Differences in poverty between people living with HIV and people not living with HIV", "Multidimensional poverty and HIV", "HIV and sanitation", and "Differences between PLHIV and general population in assets") for English-language publications from January 1, 2005, to September 31, 2025. We reviewed 52 articles published in English (Supplement A1). The studies showed that people living with HIV (PLHIV) face socioeconomic disadvantage, including material deprivation, reduced employment, and limited household assets. The studies find as association between poverty among PLHIV with poorer immunologic and virologic response to antiretroviral therapy, lower adherence, and greater comorbidity. They further show inadequate access to safe drinking water, sanitation, and hygiene, increasing diarrhoeal disease and reducing treatment absorption among PLHIV. Other studies find that people living with HIV are deprived in cooking fuels, leading to upper respiratory infections. Most studies used single indicators of poverty or were restricted to individual settings or countries. Added value of this study This study, to our knowledge, provides the first multi-country assessment of multidimensional poverty by HIV status in Eastern and Southern Africa. We find across countries, that people living with HIV (PLHIV) were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. Multidimensional poverty among PLHIV was driven by deprivations in education and employment, and deprivations in living standards such as electricity, clean cooking energy, safe drinking water, sanitation, housing, and household assets. Implications of all the available evidence Despite major gains in HIV treatment and prevention and in national poverty reduction efforts, PLHIV continue to face socioeconomic and infrastructural disadvantage. These deprivations increase PLHIV’s risk to comorbidities and undermine HIV prevention and treatment services, slowing progress toward the Sustainable Development Goals. Integrating HIV responses with poverty reduction and social protection strategies is essential. Incorporating HIV indicators into national poverty monitoring systems and prioritising investment in education, employment, and essential services can accelerate joint progress towards ending AIDS and reducing poverty, in a context of declining external funding.